Contralateral ACL Tear Research Articles

Arthroscopic ACL repair with suture tape augmentation: clinical, functional, and gait analysis outcomes at minimum 3-year follow-up.

Recent advancements in surgical techniques have led to renewed interest in ACL repair, particularly for acute, proximal tears. Suture tape augmentation (STA) has emerged as a promising technique to support ACL healing while preserving native tissue and potentially improving outcomes. This study aims to evaluate the outcomes of ACL repair with STA in patients with acute, proximal ACL tears. We retrospectively reviewed patients who underwent ACL repair with STA between June 2018 and October 2020. Inclusion criteria were acute (< 6weeks) ACL rupture, Sherman type I tears, and minimum follow-up of 3years. Exclusion criteria included mid-substance or distal ACL tears and previous knee surgeries. Clinical evaluation involved stability tests, PROMs, and gait analysis using Prokin WalkerView. Second-look arthroscopy and histological analysis were conducted on a subset of patients. Twelve consecutive patients (7 males and 5 females) with a mean age of 27.4 ± 7.9years and mean BMI of 23.3 ± 1.6kg/m2were included. Time to operation was 19.5 ± 8.7days. Mean follow-up duration was 53.2 ± 9.4months. One patient experienced a traumatic re-rupture. One had a contralateral ACL tear and one experienced hardware irritation. Clinical tests were negative for instability in all patients. Post-operative IKDC, Lysholm, and FJS-12 scores showed significant improvement (p < 0.001). All patients (100%) achieved minimal clinically important difference for all PROMs. Walking gait analysis revealed high symmetry indices for range of motion (93.50%) and step length (95.80%) with near symmetrical loading. Second-look arthroscopy showed intact repairs with healthy tissue morphology and integration. Histology revealed increased cellularity, high nuclear density, and preservation of vascular and neural components indicated by CD34 and S-100 markers. Arthroscopic ACL repair with STA provides favourable clinical, functional, and histological outcomes with low re-rupture rates when performed on acute, proximal ACL tears. This technique demonstrates fair-to-good PROMs, functional stability, and near-normal gait parameters.

No Deficits in Functional Outcomes of the Contralateral Limb Are Seen When the Hamstring Is Harvested for Augmentation of Small Diameter Ipsilateral Hamstring Autograft

To evaluate clinical outcomes of the contralateral, nonoperative limb in patients undergoing contralateral hamstring (HS) autograft harvest compared with patients undergoing ipsilateral HS autograft harvest alone. This study included 96 patients who underwent isolated anterior cruciate ligament reconstruction (ACLR) using 4-stranded HS autograft (n= 85) or 4-stranded HS autograft augmented with contralateral HS (n= 13) due to inclusion of ipsilateral graft diameter <8 mm. Isokinetic flexion and extension strength and dynamic performance of the ipsilateral and contralateral limbs and limb symmetry index (LSI) were evaluated at 6 months' postoperatively. Rates of contralateral native ACL tear at minimum 2 years also were compared. For all comparisons, P < .05 was considered statistically significant. Normalized isokinetic knee flexion and extension strength of the contralateral limb did not differ between cohorts (P= .34; P= .21, respectively). LSI for knee extension peak torque and knee flexion peak torque did not differ between cohorts (P= .44; P= .67, respectively). No difference in LSI was seen for any dynamic performance testing (single leg hop, P= .97; triple leg hop, P= .14; 6-m timed hop, P= .99). No difference was observed in International Knee Documentation Committee (P= .99) or Knee Injury and Osteoarthritis Outcome Score subscale measures (P= .39-.86). No difference in rates of contralateral knee native ACL tears were seen between cohorts (HS autograft+ contralateral HS augmentation, n= 2, 15.4%; HS autograft, n= 7, 8.4%; P= .26). In this study, at the time of return to sport, we found no differences in contralateral limb functional performance or limb symmetry measurements between patients undergoing contralateral HS autograft harvest for augmentation of smaller (<8 mm) diameter HS autografts harvested from the injured extremity. Level III, retrospective cohort study.

Poster 313: More Severe Adverse Events are Associated with Worse Patient Reported Outcome Measures following Anterior Cruciate Ligament Reconstruction with and without Lateral Extra- articular Tenodesis Augmentation – Results from the Stability Randomized Trial

Objectives: Investigate how the severity of adverse events encountered during the follow up period of the Stability Study were associated with patient reported outcomes at two years post-operative. Methods: Stability is a pragmatic, multicenter, randomized clinical trial comparing single-bundle hamstring tendon ACLR with combined ACLR + LET. Patients aged 14-25 years with an ACL deficient knee were included (n = 618). Participants completed PROMs (KOOS, IKDC, ACL-QOL), and adverse events were documented pre-operatively and at 3, 6, 12 and 24 months postoperatively. Adverse events were categorized into four groups: none (no adverse event), minor medical (resolved spontaneously or with minimum medical management), minor surgical (event such as meniscus tear or stiffness that required surgical intervention but is not a graft rupture), contralateral ACL rupture, and graft rupture. A generalized linear model was used to compare mean PROM scores with the different levels of adverse events. Results: The rate of minor medical adverse events (11.2%), minor surgical adverse events (7.4%), and ipsilateral (7%) or contralateral (3%) ACL tears at 24 months post-operative were low considering the high-risk patient profile. There was no difference in the proportion of minor medical events, minor surgical events, or contralateral ACL ruptures between the ACLR only and ACLR + LET groups (p&gt;0.05). The ACLR only group had a significantly higher rate of graft rupture (11 vs 4%, p&lt;0.01). Increasing severity of adverse events were associated with lower PROM scores at 24 months post-operative. Patients who experienced any adverse event within the two-year follow up had significantly lower outcome scores than those with no events. When only adverse events in the first year post-operative were included, the influence of minor medical and minor surgical events was largely washed out suggesting the effect on outcomes may be due to recency rather than severity. However, graft tears and contralateral ACL tears within the first year led to significantly lower scores at two-years post-operative in all outcomes (p&lt;0.01). Conclusions: Increasing severity of adverse events were associated with lower patient reported outcome measures at 2 years post-operative. Recent minor medical and minor surgical events worsened PROM scores, but this effect was largely eliminated within a year of the event. Patients who experience a graft rupture or contralateral ACL tear appear to have a significantly lower PROMs at 2 years post- operative, regardless of the time at which the tear occurs. Therefore, the benefit of the LET procedure reducing graft rupture outweighs the potential for less severe events such as hardware irritation/removal which will likely be less detrimental to patient-important outcomes.

Outcomes, Including Graft Tears, Contralateral Anterior Cruciate Ligament Tears, and All-Cause Ipsilateral Knee Operations, are Similar for Adult-type, Transphyseal, and Partial Transphyseal Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft in Pediatric and Adolescent Patients

PurposeTo compare hamstring autograft primary anterior cruciate ligament reconstruction (ACLR) techniques including adult-type/anatomic, transphyseal, and transphyseal techniques by (1) ACL graft tear, (2) contralateral ACL tear, and (3) all-cause ipsilateral reoperation.MethodsA retrospective, single-surgeon review was performed including all ACLR with hamstring autograft in pediatric and adolescent patients from 2011 to 2019. Minimum 2-year follow-up was required for patients unless a tear or reoperation was sustained before that time point. Data collected included demographics and baseline surgical variables, type of reconstruction, sporting activity, and deviations from rehabilitation protocols. Comparisons were made among hamstring autograft reconstruction groups (adult-type/anatomic, transphyseal, and partial transphyseal) for primary outcomes of graft tear, contralateral ACL tears, and all-cause ipsilateral knee reoperations, including hardware removal. Secondary surgeries performed with different surgeons were noted.ResultsIn total, 214 patients of age 15.2 ± 2.0 years with 4.1 ± 1.7-year follow-up were included. Overall graft tear rate was 11.7% (11.0% adult-type vs 19.1% transphyseal vs 5.6% partial transphyseal; P = .18). On univariate analyses, all-cause ipsilateral reoperation did not differ by technique (21.3% vs 31.0% vs 33.3%; P = .20), and neither did contralateral ACL tear (8.1% vs 9.5% vs 0%; P = .17). 21.7% of ipsilateral revision ACLRs (all adult-type) and 16.7% of patients with any reoperations had subsequent procedures performed with a different surgeon.ConclusionsThe graft tear rates in primary hamstring autograft ACLRs in the adolescent population did not significantly differ by technique (11.0% vs 19.1% vs 5.6% in adult-type, transphyseal, and partial transphyseal reconstructions, respectively). Furthermore, contralateral ACL tears (8.1% vs 9.5% vs 0%) and all-cause (including > 1/4 hardware removal) ipsilateral knee reoperations (21.3% vs 31.0% vs 33.3%) did not statistically differ. Higher powered studies may detect statistical significance in the observed differences in this study.Level of evidenceLevel IV, therapeutic case series.

Poster 265: ACL Reconstruction in Skeletally Immature Patients: Do ACL Graft Tear and Complication Rates Differ Based on Surgical Technique? A Systematic Review

Objectives:Despite a notable increase in studies investigating outcomes following ACL reconstruction (ACLR) in pediatric patients in the last decade, there remains a dearth of comparative studies designed to elucidate the optimal technique(s) for this active, high-risk sub-population. The obejctive of the current study was to compare the rates of ACL graft tear, complications, and return-to-sport (RTS) between categories of ACLR techniques in skeletally immature patients. Our hypothesis was that complication rates would be similar between techniques, while ACL graft tear rates would be greater in transphyseal (adolescent) ACLR than physeal-sparing (pediatric) ACLR.Methods:A literature search indexed from the earliest available date to January 5, 2021 was performed using the PubMed/MEDLINE, Embase, and Cochrane databases for relevant journal articles with standard inclusion/exclusion criteria utilized for systematic reviews. Further exclusions were studies of ACL repair, revision ACLR, ACLR with allograft or bone-patellar tendon-bone (BTB) autograft. Cohorts of adolescent patients undergoing transphyseal ACLR were distinguished from those of pediatric patients undergoing physeal-sparing techniques, which were further sub-classified as all-epiphyseal (AE), iliotibial band (ITB)/modified Macintosh, and partial transphyseal (PTP). Transphyseal ACLR was further classified based on graft type (hamstring vs. quadriceps autograft). Primary outcomes included reoperation for ACL graft tear, non-ACL/meniscus complications, and RTS rates. Meta-analysis for each outcome incidence rate was conducted within each subgroup, and overall, using a random effects generalized linear mixed model with logit link.Results:44 studies published between 2001 and 2021 from 15 different peer-reviewed journals were included. The total number of patients within each subgroup were as follows: Transphyseal, 2,130 patients; AE, 232 patients; ITB, 274 patients; PTP, 99 patients. The mean age of the adolescent/transphyseal group was 13.4 years (range, 11.0-14.8), compared to 12.3 years (range, 11.0-14.8) in the pediatric/physeal-sparing group (AE, 12.6 years; ITB, 11.5 years; PTP, 12.6 years). Mean duration of follow-up was reported in 93.2% of the studies and was 4.0 years (range, 1.6-10.6 years). ACL graft tear, contralateral ACL tear, complications, and RTS were not significantly different between transphyseal and physeal-sparing techniques (all p>0.05) (Table 1). ITB reconstruction was not associated with any significant differences in ACL graft tear or RTS rates compared to other physeal-sparing techniques, but did demonstrate a significantly lower complication rate (ITB, 2.9%; AE, 10.8%; PTP, 15.3%; p=0.005). The most reported non-ACL/meniscus complications were arthrofibrosis (n=35) and growth disturbance (including angular deformity and leg length discrepancy, n=23).Conclusions:Unlike the findings of smaller, single-center clinical series, we found no differences in the clinical results of younger pediatric patients undergoing physeal-sparing ACLR and relatively older, skeletally immature adolescents undergoing transphyseal ACLR when the pediatric ACLR literature was analyzed in a pooled fashion. Amongst physeal-sparing techniques, the ITB/modified-MacIntosh ACLR demonstrated a significantly lower complication rate than all-epiphyseal and partial-transphyseal ACLR. Further prospective comparative research is required to directly compare ACLR techniques for differences in ACL graft tear rates.Table 1.Rates of ACL Graft Tear, complications, and Return to Sports in Skeletally Immature Sub-Populations

No differences found in long-term outcomes of a randomized controlled trial comparing ipsilateral versus contralateral hamstring graft in ACL reconstruction.

Contralateral graft harvest in primary ACL reconstruction is relatively uncommon and the long-term comparative of this approach relative to ipsilateral harvest has not been described. The purpose of this study was to evaluate ACL graft and contralateral rupture following ipsilateral or contralateral semitendinosus and gracilis (STG) graft harvest at follow-up of a minimum 10years post-reconstruction in the treatment of a complete ACL tear. Patients from a previous randomized trial were evaluated. The primary outcome measures were ipsilateral and contralateral reinjury as well as the International Knee Documentation Committee (IKDC) knee assessment form, the ACL Quality of Life questionnaire (ACL-QoL) and the Tegner activity scale. Participants completed four different single-leg hop tests and concentric knee flexion and extension strength were assessed on an isokinetic dynamometer. Of the original 100 patients, 50 patients (41.3 ± 9.5years of age, 31 males, 19 females) reported on re-injury at 12.6 ± 1.4years post-operative. Thirty-eight patients returned for full assessment and 12 responded by mail or phone survey. There were no differences between groups for graft rupture, contralateral injury, ACL-QoL score, IKDC categorization, or anterior tibial translation, though both groups experienced a reduction in the Tegner Activity Scale from their preinjury scores. There was no difference in knee flexor and extensor isokinetic concentric strength, or single leg hop test performance. Knee flexor strength limb symmetry index was reduced when measured in the supine relative to the seated position in both groups, indicating persistent deficits in knee flexor strength when measured in the supine position. Contralateral hamstring harvest does not put patients at an increased risk of a contralateral ACL tear and long-term outcomes of ACL reconstruction do not differ based on the side of graft harvest. Contralateral STG harvest may provide a safe alternative surgical option for select patients. Level II.

ACL Reconstruction in Skeletally Immature Patients: Does Graft Retear and Complication Rates Differ Based on Surgical Technique? A Systematic Review

Background:Despite exponential increases in studies regarding ACL reconstruction (ACLR) in pediatric patients in the last two decades, there remains a dearth of comparative studies designed to elucidate the optimal technique(s) for this active, high-risk sub-population.Hypothesis/Purpose:The purpose was to compare the rates of ACL re-tear, contralateral ACL tear, complications, and return-to-sport (RTS) between categories of ACLR techniques in skeletally immature patients. The hypothesis was that complication rates would be similar between techniques, while ACL re-tear rates would be higher in transphyseal (adolescent) ACLR than physeal-sparing (pediatric) ACLR.Methods:A literature search indexed from the earliest available date to January 5, 2021 was performed using the PubMed/MEDLINE, Embase, and Cochrane databases for relevant journal articles with standard inclusion/exclusion criteria utilized for systematic reviews. Further exclusions were investigations of ACL repair, revision ACLR, and ACLR with allograft or BTB autograft. Cohorts of adolescent patients undergoing transphyseal ACLR were distinguished from those of pediatric patients undergoing physeal-sparing techniques, which were further sub-classified as all-epiphyseal (AE), iliotibial band (ITB)/modified Macintosh, and partial transphyseal (PTP). Transphyseal ACLR was further classified based on graft type (hamstring vs. quadriceps autograft). Meta-analysis for each outcome incidence rate was conducted within each subgroup and overall using a random-effects generalized linear mixed model with logit link.Results:44 studies published between 2001 and 2021 from 15 different peer-reviewed journals were included. The mean age of the adolescent/transphyseal group was 13.4 years (range, 11.0-14.8), compared to 12.3 years (range, 11.0-14.8) in the pediatric/physeal-sparing group (All-Epiphyseal, 12.6 years; ITB, 11.5 years; PTP, 12.6 years). Mean duration of follow-up was reported in 93.2% of the studies and was 4.0 years (range, 1.6-10.6 years). ACL re-tear, contralateral ACL tear, complications, and RTS were not significantly different between transphyseal and physeal-sparing techniques (all p>0.05) (Table 1). ITB demonstrated significantly lower complications (2.9%) than other physeal-sparing techniques (AE, 10.8%; PTP, 15.3%, p=0.005) and the lowest ACL re-tear rate (AE, 10.1%; ITB, 6.9%; PTP, 7.5%, p=0.20), though this difference was not significant.Conclusions:Unlike the findings of some single-center analyses, when the breadth of pediatric ACLR literature was analyzed in pooled fashion, no differences were seen between the clinical results of younger pediatric patients undergoing physeal-sparing ACLR and relatively older skeletally immature adolescents undergoing transphyseal ACLR. Amongst physeal-sparing techniques, the ITB/modified-Macintosh ACLR appears to have the lowest retear rate and a significantly lower complication rate than all-epiphyseal and partial-transphyseal ACLR.

Double-bundle anterior cruciate ligament reconstruction using autologous hamstrings with LARS augmentation demonstrates comparable outcomes to hamstrings alone, without evidence of synovitis or early osteoarthritis.

To compare the clinical and radiological outcomes in patients undergoing anterior cruciate ligament reconstruction (ACLR) with, or without, LARS augmentation. One-hundred and thirty-six patients that underwent double-bundle ACLR with (DB Hams/LARS, n = 67), or without (DB Hams, n = 69), LARS augmentation, were assessed clinically and with Magnetic Resonance Imaging (MRI) at a minimum of 7-years post-surgery. Patients were assessed via patient-reported outcome measures (PROMs), KT-1000 (laxity), isokinetic knee extensor and flexor strength and a 4-hop test battery. Limb symmetry indices (LSIs) were calculated. The Whole-Organ Magnetic Resonance Imaging Score (WORMS) evaluated knee status via MRI. Sport participation, secondary operations, ACL re-tears and contralateral ACL tears were reported. No differences (n.s.) were observed in demographics, PROMs, KT-1000 scores or strength and hop LSIs. Normal (< 3mm side-to-side differences) KT-1000 scores were observed in 64 (92.8%) and 59 (88.1%) of DB Hams and DB Hams/LARS patients, respectively. Comparative rates of satisfaction were reported. Knee flexor strength and hop test LSIs were all ˃95% in both groups, which was 94.2% and 96.7% for knee extensor strength in the DB Hams and DB Hams/LARS cohorts, respectively. While 53 (76.8%) and 52 (77.6%) of the DB Hams and DB Hams/LARS patients had returned to pivoting sports, 42 (60.9%) and 41 (61.2%) were participating in pivoting sports at the minimum 7-year review. No difference (n.s.) was observed in the WORMS (12.3 DB Hams, 16.7 DB Hams/LARS). Of the cohort assessed, 8 (11%) DB Hams and 11 (16%) DB Hams/LARS patients had undergone secondary surgery. In addition to one patient in each group that demonstrated ACL rupture on MRI, an additional cohort of patients were excluded from the current analysis due to prior re-tear (DB Hams n = 6, DB Hams/LARS n = 8) or contralateral ACL tear (DB Hams n = 4, DB Hams/LARS n = 4). Comparable outcomes were observed after double-bundle ACLR using autologous hamstrings with, or without, LARS augmentation. Therefore, while these outcomes do not justify the additional use of synthetic augmentation given the lack of further benefit and additional cost, higher rates of graft failure, synovitis and early osteoarthritic change previously reported were not observed. III.

Contralateral ACL tears strongly contribute to high rates of secondary ACL injuries in professional ski racers.

To analyse the effects of graft selection, sex, injury complexity and time to return to competition on the odds to suffer secondary ACL injury (either re-rupture or contralateral ACL tear) in professional alpine skiers. The database of a specialised joint surgery clinic was screened for professional alpine skiers who had participated in competitions at the FIS race, European Cup and World Cup level prior to having to undergo a primary ACL reconstruction, and who had returned to the same competitional level at least one year prior to the end of the observation period. The rates of secondary ACL injuries were statistically compared between athletes with hamstring and quadriceps tendon autografts, men and women, simple and complex (involvement of menisci or cartilage) primary ACL injuries, and between early (≤ 300days after primary reconstruction) and late (> 300days) returners to competition. Fourteen out of the 30 athletes included (46.7%) suffered secondary ACL injuries on average 29.4 ± 22.5months after primary reconstruction. The secondary injuries comprised five re-ruptures (16.7%) and nine contralateral ACL tears (30.0%). The odds to suffer contralateral ACL tears were non-significantly higher in patients with hamstring tendon autografts (OR 5.69, n.s.) and in those whose primary injuries were classified as simple ACL tears (OR 5.31, n.s.). None of the factors assessed was associated with the odds of graft failure. The odds of ACL-injured professional alpine ski racers to suffer secondary ACL tears are nearly 50%, with subsequent contralateral ACL injuries being more common than graft failures. While statistical significance could not be established due to a lack of power, greater odds of contralateral ACL tears were observed in athletes with hamstring tendon grafts as well as those with simple primary ACL injuries. No factors potentially predisposing athletes for graft failure could be identified. III.

Contralateral Anterior Cruciate Ligament Injuries Following Index Reconstruction in the Pediatric Athlete.

The purpose of this review is to discuss relevant anatomy and pathoanatomy in the knee following anterior cruciate ligament reconstruction, risk factors for contralateral ACL tear, and mechanisms of contralateral injuries in the pediatric population. Contralateral ACL rupture rates following ACL reconstruction (ACLR) range from 4% to 42%. Pediatric patients show increased risk compared with adults, likely due to inherent anatomical differences along with biomechanical and neuromuscular changes that occur in both the operative and contralateral knees following index ACLR. Pediatric athletes who return to sport more quickly have been found to be at increased risk for contralateral tears, as have athletes who participate in cutting and pivoting sports. Contralateral tears tend to occur via non-contact mechanisms. Pediatric patients are at increased risk of contralateral ACL injury following index ACL reconstruction compared with adults. Further study is warranted to determine appropriate biologic, functional, and rehabilitative parameters gauged toward preventing contralateral ACL tear while minimizing time lost from sport.

ACLR GRAFT STRAND NUMBER: LONG-TERM FOLLOW-UP ON 400 PATIENTS

Background:Studies on pediatric anterior cruciate ligament reconstructions (ACLRs) often focus on graft choice, as rates of these injuries have risen in recent years. Large multicenter studies have found younger age and smaller graft size to be risk factors for graft failure and contralateral tears, but despite large sample sizes these studies have not looked specifically at graft strand number. Therefore the purpose of this study was to use a large sample size to ask whether ACLR graft strand number affects long-term outcomes.Hypothesis/Purpose:Examine long-term effects of ACLR graft strand number using a large cohort.Methods:This was a retrospective comparison study of all patients presenting between 1/1/2008 and 12/31/16 for a first-time ACLR at a single pediatric hospital. After querying medical records for all ACLRs using CPT codes, graft strand number, graft diameter, and other variables were abstracted. Long-term outcomes on graft rupture, contralateral ACL tear, and subsequent meniscus injury were collected via phone calls and REDCap emails. Patient groups were compared for differences in graft strand number and diameter using bivariate analyses, and differences in long-term outcomes were analyzed using multivariate regression.Results:436 patients met the inclusion criteria also completed the long-term follow-up on outcomes. Long-term follow-up ranged from 18 months post surgery to 10 years post surgery. Patients with larger graft diameter were significantly less likely to suffer a complication (graft rupture, contralateral ACL tear, or subsequent meniscus injury) in multivariate regression (p=0.03), while strand number, sex, weight, and age showed no significant difference. Transphyseal reconstructions had larger graft diameters (8.8mm) than partial hybrid (8.6mm) and all-epiphyseal reconstructions (8.3mm) (p<0.001), but had no differences in graft strand number. Males had larger graft diameters (8.9mm) than females (8.6mm) (p=0.03), but also had no differences in graft strand number. Obese patients had larger graft diameters (9.1mm) than overweight (8.9mm) and normal weight patients (8.6mm) (p=0.002). Obese patients also had more graft strands (6.9) than overweight (6.2) or normal weight patients (6.1), but this difference was not significant (p=0.051).Conclusion:This data supports the existing literature that pediatric ACLR patients with larger graft diameters are less likely to suffer long-term complications. Using both a large patient cohort and long-term follow-up, this data also showed that graft strand number was not significantly correlated with outcomes. This suggests that strand number is not important when constructing ACLR grafts, as long as sufficient graft diameter can be achieved.

ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN ≤21 YEAR OLDS: PATELLAR VERSUS HAMSTRING TENDON AUTOGRAFTS

Background:Bone-patellar tendon-bone (BTB) and hamstring tendon (HS) are commonly used grafts for anterior cruciate ligament reconstruction (ACLR). The optimal graft choice for ACLR remains unclear. We evaluated clinical and self-reported outcomes of patients who underwent ACLR with use of a BTB autograft or double-bundle HS autograft/allograft-augmented HS autograft (HS hybrid).Hypothesis/Purpose:No significant differences in outcomes exist between graft choices.Methods:Retrospective review of prospectively collected data from patients aged ≤21 years who underwent primary ACLR with BTB or HS autograft/hybrid by one fellowship-trained orthopaedic surgeon and a minimum of 6 months follow-up. Demographics, injury characteristics, concomitant injuries, surgical and radiographic parameters were recorded. Clinical and patient self-reported outcomes (Tegner-Lysholm, pediIKDC, KOOSChild) were compared at 6-months, 1-year and latest follow-up.Results:A total of 109 subjects were included; 59 had a HS graft (55 HS autograft, 4 HS hybrid) and 50 a BTB autograft. Patients were between 13 and 21 years old at ACLR and had a follow-up of 1.5 ±1 year. Baseline comparison of demographic, injury and surgical parameters is presented in Table1.1.Graft rupture occurred in 10 patients (9.2%; 9 males and 1 female) at an average of 2 years after initial ACLR; 8 graft ruptures occurred in the HS group (13.6%, none in HS hybrids) and 2 in the BTB group (4%) (p=0.105). Parameters increasing the likelihood of a re-tear were older age at ACLR (HR: 2.348, p<0.005), a >1-year delay to surgery (HR: 4.105, p=0.048) and a concomitant chondral injury (HR: 5.476, p=0.038) (Cox proportional hazards model, Table1.2).Arthrofibrosis developed in 4 BTB patients (8%) at an average of 6 months after initial ACLR, but not in HS patients (p=0.041). At most recent follow-up, patellofemoral pain was present in 15 (28%) HS and 5 (10%) BTB patients (p=0.027) and a contralateral ACL tear had occurred in 4 patients (3.7%). No differences were seen between graft groups for knee range of motion, Lachman testing, leg raise, ligament stability and subjective scores - Tegner-Lysholm, pediIKDC, KOOSChild (p>0.05 for each comparison at 6-months, 1-year and most recent follow-up).Conclusion:In patients <21 years undergoing ACLR, BTB autograft lead to fewer graft ruptures, however, was associated with a higher rate of arthrofibrosis. Older age at surgery, a delay to surgery and chondral injuries increased the likelihood of re-tear. However, failure rates were low, and we observed no differences between graft types in terms of laxity and patient self-reported outcomes.Tables/Figures:Table 1.DemographicsHS, N=59BTB, N=50P-ValueGender, Female23 (39%)22 (44%) 0.697 Age at Surgery, years16.7 ± 1.6116.5 ± 1.33, 0.382 BMI25.2 ± 4.026.9 ± 5.3 0.146 Follow-up time, years1.84 ± 1.19, range 0.5-4.81.11 ± 0.70, range 0.5-4.21 <0.005 Injury Parameters Time Injury to Surgery, years0.41 ± 0.34, range 0.07-1.650.52 ± 0.52, range 0.09-2.520.477Laterality, Right33 (56%)25 (50%)0.568Meniscus tear, yes35 (59%)40 (80%) 0.024 Chondral Injury, yes22 (37%)16 (32%)0.687 Surgical Parameters Graft Size, mm8.6 ± 0.62, range 8-1010 ± 0.1, range 9.5-10 <0.005 Fem. Tunnel Diameter, mm8.6 ± 0.610 ± 0 <0.005 Femoral Tunnel Depth, mm29.9 ± 4.227.8 ± 1.2 0.014 Tibial Guide Angle, °55.2 ± 1.0, range 55-6058.1 ± 2.7, range 50-65 <0.005 Tibial Tunnel Diameter, mm8.6 ± 0.610 ± 0.1 <0.005 Meniscus surgery 0.050 None25 (42.4%)10 (20%) Meniscectomy12 (20.3%)15 (30%) Repair22 (37.3%)25 (50%) Chondroplasty, yes6 (10%)9 (18%) 0.274 Notchplasty, yes7 (12%)7 (14%) 0.782 Radiographic parameters Femoral Tunnel Angle, °34.6 ± 6.331.7 ± 8.3 0.064 Tibial Tunnel Angle, °64.8 ± 7.368.4 ± 7.3 0.011 PDFA, °87.3 ± 3.786.9 ± 4.20.582 Data are presented as Mean ± SD or N (%) Differences in demographic, injury, surgery and radiographic parameters between the two graft groups were compared using t-tests or Wilcoxon rank-sum tests for con.tinuous variables and chi-square or Fisher’s exact tests for categorical variables Table 2.Factors associated with time to graft ruptureDemographicsHazard Ratio95% CIP-valueGender, Male5.8880.728, 47.63 0.097 Age at Surgery, years2.3481.439, 3.831 <0.005 BMI0.9860.844, 1.153 0.863 Injury Parameters Time Injury to Surgery, ref within 0.5 years > 1 year4.1051.010,16.69 0.048 Meniscus tear, yes4.0290.499, 32.55 0.191 Chondral Injury, yes5.4761.102, 27.22 0.038 Surgical Parameters Graft type, reference HS0.9020.176, 4.629 0.902 Graft Size, mm1.2850.549, 3.007 0.563 Fem. Tunnel Diameter, mm1.2900.550, 3.022 0.558 Femoral Tunnel Depth, mm0.9750.824, 1.155 0.771 Tibial Guide Angle, °1.1760.791, 1.748 0.422 Tibial Tunnel Diameter, mm1.1010.497, 2.442 0.812 Meniscus surgery, reference none Meniscectomy5.3660.595, 48.41 0.134 Repair3.5900.397, 32.48 0.255 Chondroplasty, yes2.7660.300, 25.49 0.369 Notchplasty, yes0.5050.061, 4.152 0.525 Radiographic Parameters Femoral Tunnel Angle, °0.9640.865, 1.074 0.504 Tibial Tunnel Angle, °1.0820.980, 1.194 0.120 PDFA, °0.8710.723, 1.048 0.143 Cox proportional hazards models were used to examine associations of demographic, injury, surgery and radiographic factors with time to graft rupture.

Anterior cruciate ligament reconstruction using a double bundle hamstring autograft configuration in patients under 30 years.

BACKGROUNDAnterior cruciate ligament reconstruction (ACLR) has a high incidence of re-tear in younger patients. Despite comparable functional outcomes, the incidence of re-tear using single and double bundle ACLR methods has not been well reported.AIMTo hypothesize that double bundle hamstring ACLR has a lower graft rupture rate compared with single bundle hamstring ACLR grafts in young patients.METHODSOne hundred and twelve patients < 30 years of age at the time of primary double bundle ACLR were eligible for study participation. 91 (81.3%) could be contacted, with a mean age of 20.4 years (range 13-29) and mean post-operative follow-up time of 59 mo (range 25-107). Telephone questionnaires evaluated the incidence (and timing) of subsequent re-tear and contralateral ACL tear, further surgeries, incidence and time to return to sport, and patient satisfaction.RESULTSOf the 91 patients, there were 6 (6.6%, 95%CI: 1.4-11.7) ACL graft re-ruptures, with a mean time to re-rupture of 28 mo (range 12-84). Fourteen patients (15.4%) experienced a contralateral ACL rupture and 14 patients (15.4%) required further surgery to their ipsilateral knee. fifty patients (54.9%) returned to pre-injury level of sport. Of those < 20 years (n = 45), 4 patients (8.9%, 95%CI: 0.4-17.3) experienced a re-rupture, with mean time to re-injury 15 mo (range 12-24). Comparative analysis with existing literature and revealed a non-significant Chi-squared statistic of 2.348 (P = 0.125).CONCLUSIONA trend existed toward lower graft rupture rates in young patients undergoing double bundle ACLR utilizing a hamstring autograft, compared with rates reported after single bundle ACLR.

IS EARLY EXCELLENT ISOKINETIC AND FUNCTIONAL TESTING FOLLOWING ACL RECONSTRUCTION IN PATIENTS WITH OPEN-PHYSES PREDICTIVE OF SUBSEQUENT ACL DISRUPTION?

Introduction: It is unknown whether functional and isokinetic testing at 6 months following ACL reconstruction in patients with open-physes correlates with longer term outcomes. The purpose of this study was to compare subsequent ACL rupture risk, knee function, and activity level in patients with open-physes who had excellent 6-month testing to those who did not. Methods: Between the years of 2000 and 2015, 86 patients with open-physes underwent ACL reconstruction and had functional and isokinetic testing performed at 6-months post-operatively. Thirty-four (40%) tested in the excellent range in all categories of both functional and isokinetic testing and were labeled the excellent group. The remaining 52 (60%) patients were labeled the delayed testing group. Data regarding patient, injury, and surgical characteristics were retrospectively collected. The rate of second ACL injury as well as clinical outcome scores were collected postoperatively. Results: Graft rupture rate was 23.4% (n = 8) in the excellent group and 15.4% (n = 8) in the delayed group (p = 0.51). In the excellent group, 20.5% (n = 7) had a contralateral ACL tear versus 11.5% (n = 6) in the delayed group (p = 0.40). Five patients in the excellent group and 4 patients in the delayed group sustained both graft failure and contralateral ACL tear. The overall prevalence of second ACL injury was 29% in the excellent group and 23% in the delayed group. The delayed group returned to sport at an average of 8.8 months whereas the excellent group returned at an average of 6.6 months (p &lt; 0.01). At mean follow up of 3.59 years, the excellent group had a higher Tegner activity level (8.9 versus 8.3) than the delayed group (p &lt; 0.02). Conclusion: Pediatric patients with open-physes who had excellent isokinetic strength and functional testing 6-months postoperatively returned to sport sooner than those who did not. There was no statistical difference in either graft failure or contralateral ACL disruption between these groups. However, both groups had unacceptably high rates of second ACL injury (29% for the excellent group and 23% for the delayed group). Significance: Excellent 6 month return of strength and function was not protective of subsequent ACL disruption, the rate of which remains dismal within this pediatric population. Development of more sensitive functional measures for children could help to change these poor outcomes and guide clinicians when to allow return to sport.

No clinical difference in 10-year outcomes between standard and minimal graft debridement techniques in patients undergoing anterior cruciate ligament reconstruction using autologous hamstrings: a randomized controlled trial

Delayed ligamentization following anterior cruciate ligament reconstruction (ACLR) may result in reduced graft stiffness and strength, and an increased risk of secondary re-tear. Remnant sparing ACLR may accelerate ligamentization and proprioceptive function, theoretically reducing re-injury risk. This study sought to investigate 10-year graft failure rates and patient perceived knee functioning in those undergoing ACLR with remnant preservation (RP), versus remnant debridement (RD). A prospective RCT allocated 49 patients to ACLR with a hamstrings autograft together with a RD (n = 25) or RP (n = 24) procedure, of which 86% were clinically evaluated at 10years (22 RD, 22 RP). A detailed chart review and patient phone consultation was undertaken with all patients at 10years to evaluate the incidence (and timing) of subsequent re-tear and/or contralateral ACL tear, as well as other knee injuries/surgeries, the patient's ability to perform full work/sport duties and their perceived knee function using a numerical rating scale (NRS). No significant differences existed between groups in descriptive variables. There were 2 graft ruptures (10.0%) in the RP group and 3 (13.6%) in the RD group, with an earlier mean time to graft failure in the RD group (RD 7.7 ± 4.5 months, RP 49.5 ± 17.7months), albeit the size of this sub-sample was too small for statistical comparison. There was a significantly higher number of patients requiring ≥ 1 additional ipsilateral knee surgery in the RP group (RP = 10, RD = 4, p = 0.048). At 10years, there were no significant group differences in the percentage of patients returning to unrestricted activity, with 16 (72.7%) and 15 (75.0%) patients in the RD and RP ACLR groups, respectively, unrestricted in work/sport duties. There were no significant group differences in the functional NRS ratings. No long term clinical benefit of RP ACLR could be determined by this study with similar re-tear incidence and perceived knee function. A statistically higher number of re-operations were observed in RP ACLR patients and, while re-tears were observed later after RP versus RD ACLR, the study was underpowered to detect statistical significance. Level II (prospective randomized controlled trial).

Allograft Augmentation of Hamstring Anterior Cruciate Ligament Grafts is Associated with Increased Graft Failure

Objectives:ACL reconstruction in adolescents is commonly performed with hamstring autografts. In the adolescent population with very high activity levels, graft rupture is the most feared complication of ACL reconstruction. Young age, higher activity level, allografts, and small graft diameter have been shown to be predictors of graft failure. The applicability of this data to pediatric ACL reconstructions is limited due to heterogeneity of ages, graft constructs, and tunnel techniques. The purpose of this study is to evaluate the association of soft tissue graft constructs and graft rupture following pediatric transphyseal ACL reconstruction. Our hypothesis is that allograft-augmentation of grafts is associated with an increased risk of graft rupture.Methods:A single-institution retrospective review was performed of consecutive patients. Inclusion criteria were age less than 20 years and transphyseal ACL reconstruction with hamstring autograft, with or without allograft augmentation. Graft constructs included 4-strand doubled semitendinosus and gracilis (4-STG), 5-strand tripled semitendinosus and doubled gracilis (5-STG), 6-strand doubled gracilis and semitendinosus plus allograft (6-STGAllo), and 7-strand tripled semitendinosus and doubled gracilis plus allograft (7-STGAllo). Exclusion criteria included multiligament reconstruction and less than 6 months follow-up. The primary outcome was graft rupture.Results:Three hundred fifty-five patients (157 males, 198 females) with an average age of 15.3 years were identified to meet inclusion criteria. Graft constructs included 4-STG (198), 5-STG (91), 6-STGAllo (65), and 7-STGAllo (1). Average graft diameter was 8.3 mm 4-STG, 8.9 mm 5-STG, and 9.2 mm 6-STGAllo. Age and graft sizes were significantly different across groups with older patients (p <0.001) and larger graft sizes (p <0.001) being found in patients with allograft-augmented grafts. Mean duration of follow-up was 26 months (range 6-56 months). There were 51 graft ruptures (14.3%). The failure rate of each construct was 13.6% 4-STG, 11.9% 5-STG, and 19.7% 6-STGAllo. Time to graft failure was 16 months (range 2-40 months), with 49% of failures occurring before 12 months and 24% after 24 months. Twenty-four patients (6.7%) had a contralateral ACL tear during the follow-up period. Table 1 provides population characteristics by graft rupture status. This data suggests that patients who sustain a graft rupture may be slightly younger (p=0.07) and have lower BMI (p=0.07) than those patients without graft rupture. Odds ratios for graft failure by graft construct, controlling for age and graft size were calculated. Patients with 6-STGAllo grafts had an odds ratio of 2.6 (95% CI: 1.02, 6.50) of graft rupture as compared to 4-STG.Conclusion:ACL reconstruction with hamstring autograft combined with soft tissue allograft have a 2.6 times risk of graft rupture as compared to hamstring autograft without augmentation. In situations where the surgeon harvests an inadequately sized 4-strand autograft, we recommend tripling the semitendinosus to produce a larger graft diameter rather than augment with an allograft.

Anterior Cruciate Ligament Reconstruction in Young Females: Patellar versus Hamstring Tendon Autografts

Objectives:Female athletes are two to eight times more likely to suffer a primary ACL tear than males. Although ACL reconstruction can successfully return many athletes to their pre-injury sports, re-injury to the ipsilateral or contralateral knee can occur in over 20% of young athletes. Both female sex and younger age have been shown to be risk factors for graft failure. The optimal graft choice for this high-risk population of young female athletes remains unknown and poorly studied. We compared the clinical outcomes in young female patients who underwent ACL reconstruction at our institution using bone-patellar tendon-bone (BTB) and quadrupled hamstring (HS) autografts.Methods:Female patients aged 15-25 who underwent primary ACL reconstruction at our institution between January 2012 and May 2015 using either BTB or HS autograft were included in our review. Patients were further sub-divided into 2 age groups, 15-20 and 20-25. Patients with a prior history of ACL injury to either knee, or those with multiligament injury were excluded. Graft choice and fixation method were documented from a review of operative records. Medical records were reviewed to document the occurrence of chondral, meniscal or ligamentous injury to the ipsilateral or contralateral knee in the first two years following ACL reconstruction. Comparisons were made using the chi-square test with statistical significance set at p < 0.05.Results:A total of 256 females were included in our review with 175 in the BTB group and 81 in the HS group. There was no difference between the groups with regards to average age or time to follow-up. The majority of patients in both groups, 80% of the BTB group and 77.8% of the HS group, were between the ages of 15-20. Interference screw fixation was used in all BTB cases and 63.0% of HS cases. In the remainder of HS cases, femoral suspension and tibial screw (27.2%), and femoral cross-pins and tibial screw (9.9%) were used. In our series, 22.2% of hamstring grafts were augmented with allograft due to inadequate size. Overall, graft re-tear occurred in 6.9% of BTB patients and 12.3% of HS patients [p=0.16]. Contralateral ACL tear occurred in 7.4% of BTB patients and 6.2% of HS patients [p=0.72]. Sub-group analysis showed that 75% of BTB and 100% of HS graft re-tears occurred in females aged 15-20. Within this group, there was a significantly lower rate of graft re-tears in the BTB group (6.4%) when compared to the HS group (15.9%) [p=0.04]. Allograft augmentation was used in four of the ten HS grafts that re-tore. The risk of failure with hamstring augmentation with allograft (4/18, 22.2%) was higher than that of hamstring autograft alone (6/63, 9.5%), but this difference was not significant [p=0.18].Conclusion:The results of our study indicate that BTB autograft led to fewer graft re-tears compared to HS autograft following ACL reconstruction in female patients aged 15-20. However, this difference was not observed in females aged 20-25. Thus, further investigation regarding optimal graft choice is warranted in this age group.

Omes of ACL Reconstruction in Adolescent Female Athletes

Objectives:Background: There is limited information in the literature specifically detailing the outcomes of anterior cruciate ligament reconstruction (ACLR) in adolescent female athletes. Purpose: The purpose of this study was to (1) describe the 2-year clinical outcomes in skeletally mature adolescent female athletes undergoing ACLR and (2) determine if graft selection, concomitant injury, sport, body mass index, etc. affect outcomes.Methods:Methods: 200 consecutive skeletally mature adolescent females (207 knees) underwent primary isolated ACLR between June 2011 and January 2014 at a single orthopaedic outpatient clinic, Patients were asked to return for a physical exam and completion of subjective questionnaires.Results:Results: Clinical information was available on 114/207 knees with physical examination performed on 86 knees. Ninety-nine of 114 (86.8%) patients were able to return to play. Thirteen (11.4%) knees sustained a graft retear and eleven (9.6%) patients tore their contralateral ACL during the study period. KOOS data demonstrated a mean of 87.6 (14.1) for sports/rec and a mean of 82.1 (14.7) for quality of life subscales. All knees demonstrated a Lachman’s exam with less than 5mm side to side difference. 5 knees had rotatory instability with a pivot shift of greater than 2+. Twenty-one (21.2% ) knees underwent a subsequent nonrevision surgery on their reconstructed knee.Conclusion:Conclusions: This population of skeletally mature adolescent female athletes reported a high rate of return to play (86.8%) with ACL graft retear rate (11.4% ) and contralateral ACL tear (9.6%) consistent with other reports on male athletes undergoing ACL reconstruction. The variables of patient’s BMI, mechanism of injury, graft type, concomitant meniscal pathology at time of index procedure or undergoing a subsequent second surgery on the ipsilateral knee did not impact patient reported outcomes or physical exam findings at two years. Overall patient reported outcomes were high even in the setting of the 11.4% retear and 9.6% contralateral tear rates.

Generalized Hypermobility, Knee Hyperextension, and Outcomes After Anterior Cruciate Ligament Reconstruction: Prospective, Case-Control Study With Mean 6 Years Follow-up

To determine whether generalized hypermobility and contralateral knee hyperextension affect failure rates and patient-related outcomes after anterior cruciate ligament reconstruction (ACLR). A total of 226 consecutive patients presenting with acute ACL tears were prospectively evaluated for generalized hypermobility by a modified Beighton criteria. Minimum 2-year follow-up was achieved for 183 knees (81%). Patients underwent ACLR with either bone-patellar-tendon (BPTB) autograft (n= 46), quadrupled hamstring (HT) autograft (n= 85), or allograft tissue (n=52). KT-1000 measurements, International Knee Documentation Committee (IKDC), Cincinnati, and Lysholm scores were obtained. Forty-one of 183 consecutive patients were categorized as hypermobile. At mean 6years' follow-up (range 2-12.5years), IKDC (P= .003), Cincinnati (P= .001), and Lysholm scores (P < .001) were significantly better in the Non-Hypermobile group for patients with an intact graft. The failure rate was higher in the Hypermobile group (10knees, 24.4% failure rate) compared with the Nonhypermobile group (11 knees, 7.7% failure rate) (P= .006). The overall ACL injury rate (ACL graft injury, excessive graft laxity, plus contralateral ACL tear) was higher in the Hypermobile group (34.1%) compared with the Nonhypermobile group (12.0%) (P= .002). Heel height >5cm(P= .009) and fifth metacarpophalangeal (MCP) extension >90° (P= .006) were independently predictive of failure for the entire study population. Graft failure rates were higher and inferior subjective outcomes were observed after ACLR in patients with generalized hypermobility. Heel height and fifth MCP hyperextension were most predictive of ACL injury/reinjury and poorer outcome scores. Nearly one-third of hypermobile patients sustained a contralateral ACL tear, ipsilateral graft failure, or had excessive graft laxity. Level III, case control study.

Return to sport: Does excellent 6-month strength and function following ACL reconstruction predict midterm outcomes?

The purpose of this study was to determine whether patients with excellent 6-month functional testing after ACL reconstruction had (1) higher risk of subsequent ACL tears, (2) superior knee function, and (3) increased activity levels compared to those with delayed clearance for return to sports at midterm follow-up. A total of 223 patients underwent primary ACL reconstruction by a single surgeon and had functional and isokinetic testing performed 6months post-operatively between 1998 and 2005. Of the 223 patients, 52 (23%) made the excellent group and were allowed return to sport at 6months, and the remaining 171 (77%) constituted the delayed group. Rate of ACL graft tear and native contralateral ACL tear was compared between groups. In addition, IKDC and Tegner scores were compared at a mean 4-year follow-up. The graft rupture rate was similar in the excellent group (3.8%, n=2) compared to the delayed group (4.7%, n=8; p=0.30). However, there was a higher rate of contralateral ACL tear in the excellent group (15.4%, n=8 vs. 5.3%, n=9; p=0.003). The excellent 6-month group had superior IKDC scores (94.3±6.4 vs. 90.9±9.7; p=0.04) and Tegner scores (6.6±1.8 vs. 5.7±1.6; p=0.01). Patients with an excellent performance on their isokinetic strength and functional testing at 6months after ACL reconstruction have superior knee function and higher activity levels at midterm follow-up. However, these patients appear to be at greater risk of contralateral ACL injury, which may be related to their increased activity level. When isokinetic and functional testing is used for return-to-sport decisions, physicians should caution patients about the risk of contralateral ACL injury for high performing patients. Retrospective Review with Control, Level III.